Chapter
ERCP in the New Millennium
Evolution of the ERCP Room
Staffing for the ERCP Procedure
Radiologic Imaging Equipment
Pre- and Post-Procedure Work Area
Anesthesia or Sedation Work Area
Nursing and Technician Work Area
3 Radiologic Issues and Radiation Safety during ERCP
Fluoroscopic Imaging Systems
Radiation Dose Management in Fluoroscopic Procedures
Occupational Ionizing Radiation Exposure
Creating and Viewing Images
Pancreatic Duct Evaluation
General Imaging Considerations
4 Endoscopes, Guidewires, and Accessories
Forward-Viewing Endoscopes
Balloon-Assisted Enteroscopes
Standard Cannulation Catheters
Exchange Assistance Devices (Short-Wire ERCP Systems)
Rapid Exchange Biliary System
Self-Expandable Metal Stents
Nasobiliary and Pancreatic Drainage Catheters
Stricture Dilation Devices
Stone Extraction Accessories
Intraductal Ultrasound Probes
Probe-Based Confocal Laser Endomicroscopy (pCLE)
Radiographic Contrast Media Used in ERCP
Accessories for Use in Patients with Altered Anatomy
Single-Use versus Reusable Accessories
Role of the U.S. Food and Drug Administration in Device Evaluation and Monitoring
Defining the Continuum of Sedation
Defining Sedation-Related Adverse Events
Safety of Alternative Approaches to Sedation in ERCP
Anesthesiologist-Administered Sedation
Nonanesthesiologist-Administered (Endoscopist-Administered) Sedation
6 Indications for and Contraindications to ERCP
Indications for and Contraindications to ERCP
Contraindications to ERCP
7 Adverse Events of ERCP:
Definitions of Complications, Adverse Events, Unplanned Events and Other Negative Outcomes
Analyses of Adverse Event Rates
Overall Adverse Events of ERCP and Sphincterotomy
Patient-Related Risk Factors for Post-ERCP Pancreatitis
Technique-Related Risk Factors for Post-ERCP Pancreatitis
Specific Techniques to Reduce Risk of Post-ERCP Pancreatitis
Prevention and Treatment of Post-ERCP Pancreatitis
Risk Factors for Hemorrhage after Sphincterotomy
Methods to Prevent and Treat Hemorrhage
Cholangitis and Cholecystitis
Long-Term Adverse Events and Sequelae
Operator Experience and Adverse Events
Clinical Training in ERCP
Maintenance of ERCP Skills
Training Models and Simulators
ERCP Training in Live Animals
Ex Vivo Porcine Tissue Models (Composite and Explanted Organ Simulators)
Comparison of ERCP Training Models
Acquiring Teaching Skills as a Tutor for Hands-On Workshops
Open Questions and Perspectives for ERCP Training in the Future
Should This Patient Undergo ERCP?
When, Where, and by Whom?
Evaluation of the Patient Prior to ERCP
History and Physical Examination
Review of Imaging Studies
Preparing the Patient—Day(s) Prior to ERCP
Management of Antithrombotic Agents
Method of Sedation, Proper Personnel, and Patient Monitoring
Selecting Sedation for ERCP
Proper Monitoring and Intervention Equipment
Preparing the Endoscopy Team
Preparing the Patient—Day of the ERCP
Periprocedural Antibiotics
Positioning the Patient and Preparing for Radiography
Reviewing Intravenous Access and Allergies
10 Principles of Electrosurgery
A Brief History of Electrosurgery and ERCP
Basics of Electricity as Applied to Electrosurgery
Monopolar versus Bipolar Circuits
Neuromuscular Stimulation
Clinical Applications of Electrosurgery in ERCP
Needle-Knife Access Papillotomy
Electrohydraulic Lithotripsy (EHL)
Ampullectomy or Papillectomy
Pseudocyst Drainage and Necrosectomy
Radiofrequency Ablation (RFA) in the Bile Duct
11 Quality Issues and Measures in ERCP
Preprocedure Quality Indicators
Assessment of Procedural Difficulty
Intraprocedure Quality Indicators
Removal of Common Bile Duct Stones
Stent Placement for Biliary Obstruction below the Bifurcation
Postprocedure Quality Indicators
Comprehensive Documentation
Initiating Quality Measurements
12 Medicolegal Issues in ERCP
How Often Are Gastroenterologists and Endoscopists Sued?
How Common Are Lawsuits Involving ERCP?
What Are The Key Legal Principles?
Elements of a Malpractice Case: The Principles of Tort Law
Standards of Care and Guidelines
Theory of Informed Consent
Exceptions to Informed Consent
Legal Consequences of Failing to Obtain Informed Consent
Why Do ERCP Lawsuits Occur?
Poor Endoscopic Technique
Sedation or Anesthesia Problems
How to Minimize the Risk of Litigation
Training and Accountability
Levels of Complexity in Training and Practice
How Is Competence Ensured and Documented?
Recognizing Higher Risk Situations
The Context of the Procedure
Doing Informed Consent Right
Documenting the Consent Process: “He Said, She Said”
Special Care Needed with “Open Access” and Urgent ERCP
Live Teaching Demonstrations
13 Cannulation of the Major Papilla
Establishing the Duodenal Position
Devices and Equipment (see also Chapter 4)
Papilla Assessment and Basic Technique
Periampullary Diverticulum
Repeated Cannulation of the Pancreatic Duct without Biliary Access
Needle-Knife Sphincterotomy (see also Chapter 14)
Cannulation of the Pancreatic Duct
Quality and Enhancing Outcomes (see also Chapter 11)
14 Access (Precut) Papillotomy
Indication for Precut Papillotomy
Needle-Knife from the Orifice
Needle-Knife above the Orifice (Fistulotomy)
Needle Knife with an Insulated Tip
Short-Nose Precut Sphincterotomy
Transpancreatic Sphincterotomy
Unconventional Techniques
15 Sphincter of Oddi Manometry
Technical Performance of SOM (Video 15.1)
16 Biliary Sphincterotomy
Description of the Technique
Instruments (see also Chapter 4)
ES in Patients with Difficult Anatomy
Adverse Events and Their Management
Long-Term Consequences of ES
17 Balloon Dilation of the Native and Postsphincterotomy Papilla
Technique of Balloon Dilation of the Native Papilla
Limitations and Recommendation of EPBD
Endoscopic Papillary Large Balloon Dilation (EPLBD) after Endoscopic Biliary Sphincterotomy (ES)
Technique of Large Balloon Dilation of Postsphincterotomy Papilla
Adverse Events of EPLBD after ES
EPLBD without Preceding Sphincterotomy (ES)
Indications and Contraindications
Removal of an Impacted Ampullary Stone
Relative Cost of Stone Retrieval Balloons and Baskets
Electrohydraulic Lithotripsy
Management of Cystic Duct Stones
Adverse Events and Their Management
19 Pancreatic Sphincterotomy
Endoscopic Pancreatic Sphincterotomy
Needle-Knife Sphincterotomy
Precut Pancreatic Sphincterotomy
Indications for Pancreatic Sphincterotomy
Pancreatic Sphincterotomy as Primary Therapy
Pancreas Divisum and Sphincter of Oddi Dysfunction
Pancreatic Sphincterotomy as Secondary Therapy
Adverse Events of Pancreatic Sphincterotomy
The Cost of Pancreatic Sphincterotomy
20 Minor Papilla Cannulation and Sphincterotomy
Indications for Minor Papilla Cannulation and Sphincterotomy
Sedation, Supplemental Drugs, and ERCP Accessories
Minor Papilla Cannulation (Video 20.1)
Cannulating the Minor Papilla in Difficult Cases
Minor Papilla Sphincterotomy
Techniques for Minor Papilla Sphincterotomy
Sphincterotomy with Pull-Type Sphincterotome
Sphincterotomy with Needle Knife over Pancreatic Stent
Sphincterotomy with Wire-Assisted Needle Knife
Pull-Type or Needle-Knife Sphincterotome: Pros and Cons
Postprocedural Stenting of the Minor Papilla
Precut Sphincterotomy Technique
Repeat Minor Papilla Sphincterotomy
Outcomes of Minor Papilla Sphincterotomy
21 Plastic Pancreaticobiliary Stents and Nasopancreaticobiliary Tubes:
Description of Technique: Biliary
Distal Biliary Obstruction
Stents for Irretrievable Bile Duct Stones
Hilar Biliary Obstruction
Pancreatic Duct Stent Insertion
Drainage of Pancreatic Fluid Collections
Indications and Contraindications
22 Biliary Metal Stent Insertion
SEMS versus Plastic Stents
SEMS for Benign Biliary Disease
Covered versus Uncovered SEMS
Techniques for SEMS Placement
Endoscopic and Fluoroscopic Guidance
Adverse Events and Their Management
23 Pancreaticobiliary Stent Removal:
Removal of Biliary Stents
Indications and Contraindications
Direct Grasping Technique
Indirect Grasping Technique
Soehendra Stent Retriever Technique
Fogarty Balloon Technique
Covered Stent in Uncovered Stent Technique
Other Techniques and Variations of the Previous Techniques
Adverse Events and Management
Relative Costs and Choice of Technique
Removal of Pancreatic Stents
Indications and Contraindications
Adverse Events and Management
Relative Costs and Choice of Technique
24 Papillectomy and Ampullectomy
Initial Endoscopic Assessment
1. Conventional Endoscopy
2. Endoscopic Ultrasound (EUS) and Intraductal Endoscopic Ultrasound (IDUS)
3. Endoscopic Retrograde Cholangiopancreatography (ERCP)
2. Electrosurgical Currents: Cutting versus Coagulation
3. En Bloc versus Piecemeal Resection
4. Role of Submucosal Injection
5. Infrequently Performed Novel Techniques
6. Specimen Retrieval and Preparation
7. Pre-Resection Sphincterotomy
8. Postpapillectomy Sphincterotomy
9. Postpapillectomy Stents: Pancreatic and Biliary
10. Adjunctive Therapy and Thermal Ablation
Postpapillectomy Surveillance
Indications and Contraindications (Box 24.2)
Adverse Events and Their Management (Boxes 24.3 and 24.4)
Light Source and Image Processor
Differentiation of Stenosis of the Main Pancreatic Duct (Benign or Malignant)
Intraductal Papillary Mucinous Neoplasm (IPMN)
Further Investigation and Management of Chronic Pancreatitis
Video Pancreatoscopic Findings in Various Types of Pancreatic Diseases
New Trends in Peroral Pancreatoscopy
Videocholangioscopy Using the Mother-Baby System
Description of the Technique
Technique: Diagnostic and Therapeutic
Adverse Events and Limitations
Videocholangioscopy by the Direct Insertion System
Description of the Technique
Technique: Diagnostic and Therapeutic
Adverse Events and Limitations
Single-Operator Cholangiopancreatoscopy Using the Spyglass Direct Visualization System
Clinical Use and Efficacy (Figs. 26.10 to 26.12)
Difficult Biliary Stones Using SOC-S
Pancreatic Stone Therapy Using SOC-S
SOC-S Evaluation of Indeterminate Biliary Strictures
Reimbursement and Limitations
Description of Technique (Box 27.1)
Indications and Contraindications (Box 27.2)
Diagnostic and Therapeutic Indications
Cholelithiasis and Choledocholithiasis
Biliary Strictures and Leaks
Unusual Biliary Infections
Sphincter of Oddi Dysmotility
Persistent, Recurrent, and Chronic Pancreatitis
Alternative Diagnostic Imaging Modalities
Radiation Exposure during ERCP
Positioning, Sedation, and Medications
Outcomes after ERCP during Pregnancy
29 ERCP in Surgically Altered Anatomy
Surgery That May Affect the Performance or Interpretation of ERCP
Upper GI Bypass Surgery without Resection
Malabsorptive-Jejunoileal Bypass
Biliopancreatic Diversion and Duodenal Switch
Conventional Whipple Procedure
Pylorus-Preserving Whipple Procedure
Other Pancreatic Resective Surgery
Pancreatic Duct Drainage Procedures
Roux-en-Y Hepaticojejunostomy
Hepaticocutaneous Jejunostomy
Endoscopic Techniques Commonly Employed for ERCP in Surgically Altered Anatomy
Performing a Rendezvous Procedure
Choosing an Intestinal Anastomotic Opening to Enter
Navigating through the Small Intestine
30 Echoendoscopic Ultrasound–Guided Biliary Drainage
Interventional Echoendoscopes
Needles and Accessories for Drainage
EUS-Guided Rendezvous Technique (Fig. 30.2)
EUS-Guided Choledochoduodenostomy
Technique of Left Hepaticogastrostomy under EUS Guidance (HGE) (Fig. 30.3)
Place of the Biliodigestive Anastomosis Guided by EUS in Comparison with ERCP
31 Endoscopic Ultrasound–Assisted Access to the Pancreatic Duct
Preprocedure Considerations
Transpapillary/Transanastomotic Approach (with Retrograde Stent Placement)
Transpapillary/Transanastomotic Approach (with Antegrade Stent Placement)
Transluminal Access and Drainage
Technical Success and Outcome
Technical Difficulties, Adverse Events, and Their Management
III Approach to Clinical Problems
32 Pancreas Divisum, Biliary Cysts, and Other Congenital Anomalies
Anomalous Pancreaticobiliary Junction
Variations of Bile Duct Anatomy
Embryology and Terminology
Association with Pancreatitis
Incomplete Pancreas Divisum
33 Approach to the Dilated Bile Duct and Pneumobilia
Defining Dilated Bile Ducts
Magnetic Resonance Imaging
Approach to the Dilated Duct
Approach to the Patient with Pneumobilia
34 The Dilated Pancreatic Duct
Diagnostic Workup and Evaluation
Transabdominal Ultrasound, CT, and MRI
Endoscopic Ultrasound (EUS)
Intraductal Ultrasound (IDUS)
Gastrointestinal Stromal Tumor (GIST)
Ampullary Adenomas and FAP Syndrome
Pathogenesis of Ampullary Adenoma and FAP Syndrome
36 Malignant Biliary Obstruction:
Differential Diagnosis of Distal Biliary Malignancies and Imaging Techniques
An Approach to the Management of Patients with Distal Biliary Malignancies
Indications for Biliary Stenting
Self-Expandable Metal Stents
Stent Choices for Palliation of Malignant Biliary Obstruction
Percutaneous Approach to Biliary Drainage
37 Malignant Biliary Obstruction of the Hilum and Proximal Bile Ducts
Bismuth-Corlette Classification
Diagnostic Evaluation in Patients with Hilar and Proximal Biliary Obstruction
Intraductal Ultrasound (IDUS)
Confocal Laser Endomicroscopy (CLE)
Narrow Band Imaging (NBI) and Chromoendoscopy
Preoperative Biliary Drainage
Biliary Drainage in Patients with Hilar or Proximal Biliary Obstruction
EUS-Guided Biliary Drainage
Image-Guided Biliary Drainage
SEMS versus Plastic Stents
Local Ablative Techniques
Photodynamic Therapy (PDT)
Radiofrequency Ablation (RFA)
38 Indeterminate Biliary Stricture
Noninvasive Cross-Sectional Imaging
Invasive Imaging Techniques
Tissue Acquisition and Pathologic Investigations
Intraductal Transmucosal Fine-Needle Aspiration
Intraductal Forceps Biopsies
Confocal Laser Endomicroscopy
39 Combined Biliary and Duodenal Obstruction
Comparison of Surgical versus Endoscopic Palliation
Endoscopic Treatment of Type 1 Obstruction
Endoscopic Treatment of Type 2 Obstruction
Endoscopic Treatment of Type 3 Obstruction
Clinical Trials Regarding Endoscopic Treatment of Combined Biliary and Duodenal Obstruction
40 Benign Biliary Strictures
Negotiating the Stricture
Dilation of the Stricture
Self-Expandable Metal Stents
41 Biliary Surgery Adverse Events Including Liver Transplantation
Physiological Basis of ERCP Techniques in the Treatment of Biliary Surgery Adverse Events
Decreasing Intrabiliary Pressure
ERCP for Management of Biliary Adverse Events Following Laparoscopic Cholecystectomy (LC)
Nature and Magnitude of Biliary Injury
Treatment of Infected Biliary Collections and Related Infectious Adverse Events
ERCP and Bile Leaks after Hepatic Resection
Retained Common Bile Stones
Biliary Adverse Events of T-Tubes
Postcholecystectomy Syndrome
Endoscopic Treatment of Biliary Disorders through a Subcutaneously Placed Afferent Limb of a Choledochojejunostomy
Biliary Adverse Events in Patients with Surgically Altered Anatomy
Special Considerations for Liver Transplant Patients
Bile Leaks and Fistulae after Liver Transplantation
Biliary Strictures Following Liver Transplantation
Filling Defects and the Biliary Cast Syndrome
Endoscopic Management of Recurrent Biliary Disease after Liver Transplantation
Miscellaneous Transplant ERCP
42 ERCP for Acute and Chronic Adverse Events of Pancreatic Surgery and Pancreatic Trauma
Pancreaticoduodenectomy (Whipple Operation) with and without Pylorus Preservation
Role of Endoscopy in the Management of Adverse Events
Bilioenteric Anastomotic Stricture
Afferent Limb Obstruction
Other Treatment Options for Biliary and Pancreatic Ductal Obstruction
Interventional Radiology (IR) and ERCP
Endoscopic Ultrasound (EUS) and ERCP
Distal and Central Pancreatectomy
Role of Endoscopy in Patients with Distal Pancreatectomy
Puestow or Longitudinal Pancreatojejunostomy
Role of ERCP in Pancreatic Trauma
Evaluation of Patients with Suspected Choledocholithiasis
MRC, EUS, and Other Imaging Modalities in the Diagnosis of Choledocholithiasis
Technique of ERCP in Extraction of Bile Duct Stones
Patient Preparation (see also Chapter 9)
Biliary Cannulation, Cholangiography and Sphincterotomy
Techniques and Devices in Stone Extraction and Biliary Drainage
Balloon Sphincter Dilation
Sphincterotomy versus Sphincterotomy and Large Balloon Sphincteroplasty (see also Chapter 17)
The Role of Biliary Stents
Difficult Bile Duct Stones
Extra or Intracorporeal Lithotripsy
Stricture Disease and Hepaticolithiasis
Surgically Altered Anatomy of the Upper Gastrointestinal Tract
44 Pancreaticobiliary Pain and Suspected Sphincter of Oddi Dysfunction
Upper Abdominal Pain with Gallbladder In Situ
Informed Consent for ERCP for Suspected SOD
Sphincter of Oddi Manometry
Prevention of Post-ERCP Pancreatitis
Unexplained Acute Pancreatitis
Evaluation of Patients with Recurrent Pain after Endoscopic Intervention for Sphincter of Oddi Dysfunction
45 Sclerosing Cholangitis
Diagnosis and Natural History
Introduction and Scientific Basis
Indications and Contraindications
Introduction and Scientific Basis (Box 45.2)
Indications and Contraindications
Adverse Events and Their Management
Introduction and Scientific Basis
Indications and Contraindications
Adverse Events and Their Management
46 Tropical Parasitic Infestations
ERCP and Endotherapy for Hepatobiliary Ascariasis
Intrabiliary Rupture of a Hydatid Cyst
Biliary Adverse Events Following Surgery
Role of ERCP and Endoscopic Ultrasonography
47 Recurrent Pyogenic Cholangitis
Initial Management of the Patient with Cholangitis
Specific Treatment of Intrahepatic Stones
Description of Techniques
Standard ERCP and Peroral Cholangioscopy
Percutaneous Transhepatic Cholangioscopy
1. Percutaneous Transhepatic Biliary Drainage (PTBD)
3. Percutaneous Transhepatic Cholangioscopic Examination
Postoperative Cholangioscopy (POCS)
Techniques for Cholangioscopic Stone Removal
Results of Cholangioscopic Stone Removal
Indications and Contraindications
Adverse Events and Their Management
Long-Term Management of RPC
48 Cystic Lesions of the Pancreas
Risk Factors for Cystic Lesions
Intraductal Papillary Mucinous Neoplasms
Mucinous Cystic Neoplasms
Solid Pseudopapillary Neoplasms
Cystic Neuroendocrine Neoplasms
49 Unexplained Acute Pancreatitis
Pathophysiology and the Role of ERCP, EUS, and MRCP
Diagnostic Findings and the Timing of ERCP, EUS, and MRCP
Sphincter of Oddi Dysfunction
Yield of ERCP for IAP and IARP
Outcomes of Endoscopic Therapy in IARP
50 Biliary Intervention in Acute Gallstone Pancreatitis
Diagnosis of Acute Gallstone Pancreatitis
Assessment of Severity of Acute Pancreatitis
Treatment of Acute Gallstone Pancreatitis
Endoscopic Therapy for Acute Gallstone Pancreatitis
Early ERCP with or without ES in AGP: the Studies
Early ERCP with or without ES in AGP: Timing
Early ERCP with or without ES in AGP: Systematic Reviews
Early ERCP with or without ES in AGP: Summary
Role of MRCP versus Endoscopic Ultrasound (EUS)
Cholecystectomy after AGP
Algorithm for the Management of Acute Gallstone Pancreatitis
51 Pancreatic Interventions in Acute Pancreatitis:
Epidemiology of Ductal Disruption
Management Strategies (Box 51.4)
Pancreatic Ascites and High-Amylase Pleural Effusions
Pancreaticoenteric Fistulae and Acute Pancreatic Trauma
Adverse Events (Box 51.7)
Endoscopic Treatment: Ductal Decompression by Managing Stones and Strictures
Preprocedural Planning (see also Chapter 9)
MPD Cannulation and Endoscopic Pancreatic Sphincterotomy
Extracorporeal Shock Wave Lithotripsy
Stone Extraction and Dilation
Impact of Endoscopic Pancreatic Ductal Drainage on Pancreatic Endocrine and Exocrine Function
53 Endoscopic Drainage of Pancreatic Pseudocysts, Abscesses, and Walled-Off (Organized) Necrosis
Specific Types of Fluid Collections
Collections Composed Entirely or Predominantly of Liquid
Indications for Drainage of Liquified Collections
Transmural Entry Techniques
EUS-Guided Transmural Drainage
Non-EUS-Guided Transmural Drainage
Endoscopic Drainage of Organized Pancreatic Necrosis
Results of Endoscopic Therapy of Pancreatic Fluid Collections
Outcome Differences Following Endoscopic Drainage of Pancreatic Fluid Collections
Role of Endoscopic Experience
Adverse Events of Endoscopic Therapy of Pancreatic Fluid Collections
ERCP
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